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SubscriptionsSites I Read
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| New CEO not only wants to know how come we aren't earning any money, but also my plans ("models", actually)for doubling for patient volume immediately, since my employer is having trouble meeting payroll. Things don't look real good for the future of Conewango Valley Medical Center, since I'm just a doctor, not an MBA. | | |
| I would love to fill the virtual airwaves with true accounts of my brilliant genius-like deeds at the Conewango Medical Center, where your hero--against all odds and without the benefit of modern diagnostic equipment--labors selflessly to save life and limb. Unfortunately I believe in a measure of honesty and balance in reporting.
And so, read a brief anecdote of a young man who is now blind in one eye. And how I wish I had a slit lamp.
Back in January a seventeen year-old kid is brought in by his dad, complaining of pain and swelling in the right eye for the past day or so. The eye is watery, and hard to see out of. It seems it may have been related to feeling a speck fly in the eye several days ago while hammering. In fact, after staining the cornea with fluorescein and holding a blacklight to it, I notice a tiny scratch on the lower sclera, the white part. No big deal. He gets some antibiotic ointment, topical anesthetic and a patch for the eye, along with explicit instructions to call in a day or two for a referral to the ophthalmologist uptown if it isn't totally healed, or if the vision is still blurry. This is a reasonable plan for a family with no insurance and no car.
Father drives the buggy to the phone next Monday to tell my nurse that the eye is all better, and he doesn't want to go up to the eye specialist. Great news, right?
So guess who shows up at the clinic last month with his dad in tow, informing me that he has not had any vision in that eye for over two weeks. Two weeks!
I got him up to the nearest ophthalmologist the same day, and he promptly ordered a CT scan. This confirmed the presence of two metal fragments lodged all the way back in his retina, fragments that the specialist could readily see with his slit lamp. In fact, he invited Dad to peer through the lens and take a look for himself. Junior was then promptly shipped to a retinal surgeon in Buffalo, who subsequently needed to remove almost the entire retina in order to prevent gangrene.
Ugh! Father is naturally a little put out, since the specialist told him that the eye could easily have been saved if he'd gotten to it right away. Sometimes being a country doctor is less fun than other days!
Our new CEO is coming out to the clinic next week to find out how come we aren't earning any money. It must be 'cuz we waste it all on expensive newfangled technology!
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| I am a country doctor, a GP, or more precisely a Family Practitioner, having aspired to this field following my diagnosis and treatment by a deep-in-the-woods physician up in L'anse, Michigan back in 1977. I was amazed by this doctor's ability to examine my swollen blistered excoriated body, ask a directed history of me and those who'd carried me out of the Northwoods to this tiny clinic, and make an accurate diagnosis in the space of five minutes. After an injection and a stop at the fortunately open pharmacy for his properly-prescribed medication I was on the road to recovery, and firmly planted on the path to a career in rural medicine.
I've told that story many times in the past for those who care to listen, often as part of a testimony at church, and as a stock answer to the medical school admissions interviewers' query: Why do you think you want to be a doctor?
Of course, I did not think to remember the doctor's name, and I'm sure he is long since retired, but I'd like him to know he made in indelible imprint on my life (and may have even saved it outright, such was the seriousness of my condition). And part of my aspiration at the time involved thinking the following: someday by the grace of God I'll be able to examine, interview, and diagnose a patient with a deadly condition in my rural clinic, without the benefit of x-rays and tests, and prescribe a treatment that will save his life.
In point of fact this may occur fairly frequently in my practice, but as my personal life-evaluations lately have made me wonder if there is any room left in the Western world for medical dinosaurs such as myself, the events of the past two days are standouts.
Please understand, we were busy yesterday, standing room only, and my 2:00 pm patient in for ER follow-up looked just awful. It seems he'd undergone cardiac bypass surgery the week before (a procedure we had to talk him into doing, as he'd lost his mother due to complications of heart surgery), been discharged home after 4 days, then back to the ER two days later with a fainting spell that was ascribed to Potassium deficiency and sent home. And now five days later in my office. No discharge summary from the big hospital in Buffalo, no labs or X-rays from ER. Looked like total cr__. Without any information from the hospitals there wasnot much I could do besides a thorough 45-minute examination and promise him and his wife to review his case thoroughly and get back to him. It was obvious that he was experiencing a serious complication of his surgery, as he was actually in fine shape before we had him repaired. A weird complication not normally diagnosed in Conewango, something I'd never seen before in this setting.
Going through the differential diagnosis in my mind my cerebral cortex sorted out decades of learned and observed data, separating the useful from the trivial, rejecting diagnosis after diagnosis until Ka-ching! came the answer: your left hemispheric cortex thinks it might be a pulmonary embolus. My right brain then took the same information and drew circles around it, coloring it in with fluorescent colors and adding a little bit a background music, and grudgingly agreed that the Gestalt of this whole case clearly was consistent with PE. Ten minutes before closing our fax machine spat out the radiologist's reading of the CXR from his recent ER visit: multiple tiny calcified granulomata. An entirely benign finding in almost all cases, certainly nothing to make someone weak enough to have a syncopal episode.
Ah, but didn't he have a pre-operative chest film at the same hospital? Yes, but there was no mention of a comparison on the emergency x-rays. So yours truly the country doctor who is too unsophisticated to make it in private practice in the rich suburbs looks at the pre-op chest x-ray report, sees that there were no granulomata just a few weeks ago, and remembers that this is indeed an uncommon finding in multiple pulmonary emboli. He phones the perplexed patient to go to the lab next morning for a specialized blood test measuring a certain intravascular clotting by-product called "d-dimer", and to wait by the phone for further instructions.
Sure enough, as soon as I arrived at work today there was a message from the lab that his d-dimer is positive. I have my overworked, underpaid nurse arrange for a specialized big-city test called Spiral CT Angiogram as soon as possible to avoid going back to the ER (remenber, he'd been there already, and their doctors are under no compulsion to listen to my suggestions). We argued with his insurance company for Prior Authorization, and then argued with the nurse running the test at Buffalo General because I wrote the wrong word on his order slip and she was ready to send him back home.
Not unexpectedly, around six pm my dinner was interupted by the radiologist calling from Buffalo General to inform me that my patient had multiple pulmonary emboli, and he was being sent immediately downstairs to their ER for urgent evaluation and administration of lifesaving anticoagulation therapy. So even though I'm not the one actually dripping the heparin into his veins to dissolve the frequently-fatal blood clots in his lungs, this patient was saved from his mother's fate by my willingness to sit an extra forty-five minutes with nothing but my five senses and two cerebral hemispheres, and to argue with obstacle-persons to get done what needed doing till he got the treatment he needs.
I came back to the dinner table to share the good news with my family that I had saved someone's life today, and gave them the short version of the above narrative. They were thoroughly underwhelmed.
Sam: That's good, Dad? What do you get for it?
Well, nothing, actually. Nothing at all, just my usual hourly salary. Evauation and Management reimbursement from his insurance will probably pay my employer less than one-tenth of what the mis-diagnosing 30 year-old in the ER got. Of course, I can share with Ranger Bill the Pride and Satisfaction of a Job Well Done.
Not to mention that I finally have something worth writing about on my Xanga site. Even if no one reads it besides you, I appreciate your taking the time to scan my rantings. Blessings to you.
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| So here we are, back from our annual trip to Florida with my parents, settling in for another imminent winter. A new quiz season has started, with Rhoda showing great promise as a ten-year-old rookie, and we're making plans for upcoming holidays. My concussion symptoms are a little less prominent, I think, and there should be a follow-up scan next week to determine whether my little skull tumor is growing. In short, my life probably would seem a bit slow and boring to some. Which is not necessarily a bad thing. It was definitely cool to have Zach and Sarah join us for the Orlando trip. I hope they had as good a time as we had. I'm really excited about her new enterprise retailing stationary produced by the Varanasi Widows Home. And it was nice to spend time there with Doug in addition to Cliff and his family. Man, have my writing skills deteriorated! What a boring post! I think I'll quit right now and try again later after I've thought of something worthwhile to say. | | |
| So now there are only four kids in the Mast household, the oldest being ten years old. The last time Esther and I were in this situation was back in early 1995, so we should really feel very young right about now. And we should also feel we have some experience raising pre-teens. Rhoda seems a little bummed that the Jamestown Jammers didn't win the NY-Penn Championship, losing the three-game series to the Batavia Muckdogs. I say, if you're gonna lose a championship, it might as well be to a team with a name like The Muckdogs... | | |
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